Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

A Case of Thoracic Aortic Aneurysm with Hemoptysis as the First Symptom

This article reports a case of thoracic aortic aneurysm with hemoptysis as the first clinical manifestation, hemoptysis as the first clinical manifestation is very uncommon and to the best of our knowledge, only twenty of such cases have been previously reported. The case report presented here constitutes the longest course of the disease reported in medical literature, and good recovery after thoracic endovascular aortic repair, may help us to increase the understanding and diagnosis of the disease.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.

Innovation in pathogenesis and management of aortic aneurysm

Aortic aneurysm(AA)refers to the persistent dilatation of the aorta,exceeding three centimeters.Investigating the pathophysiology of this condition is important for its prevention and management,given its responsibility for more than 25000 deaths in the United States.AAs are classified based on their location or morphology.various pathophysiologic pathways including inflammation,the immune system and atherosclerosis have been implicated in its development.Inflammatory markers such as transforming growth factorβ,interleukin-1β,tumor necrosis factor-α,matrix metalloproteinase-2 and many more may contribute to this phenomenon.Several genetic disorders such as Marfan syndrome,Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease.Recent years has seen the investigation of novel management of AA,exploring the implication of different immune suppressors,the role of radiation in shrinkage and prevention,as well as minimally invasive and newly hypothesized surgical methods.In this narrative review,we aim to present the new contributing factors involved in pathophysiology of AA.We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Clinical application of retrograde cerebral perfusion for brain protection during the surgery of ascending aortic aneurysm:50 cases report

Objective To assess retrospectively the effects of different protective methods on brain in ascending aortic aneurysm surgery. Methods In 65 patients, aneurysm was dissected to the aortic arch or right arch. To protect brain, deep hypotermic circulatory arrest ( DHCA.) combined with retrograde cerebral perfusion ( RCP) June 2003 Vol11 No2 through the superior vena cava ( n = 50) and simple DHCA ( n = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups at different plase, and perfusion blood distribution and oxygen content difference between the perfused and returned blood were measured in some RCP patients. Results The DHCA time was 35.9 ± 8 min (10. 0 - 63. 0 min) and DHCA+ RCP time was 45.5 ± 17. 2 min (16. 0 - 81. 0 min)The resuscitationtime was 7.1 ± 1.6 h (4.4 - 9.4H)in DHCA patients and 5.4±2.2h(2.0-9.0 h)in RCP patients. Operation death was 3/15 in the DHCA group and 1/50 in the RCP patients. Central nervous complication

Atherosclerotic Descending Aortic Aneurysms. Pros and Cons of Surgery

Within the last few years, there has been a strong trend to rethink the issue of management of atherosclerotic descending thoracic and abdominal aortic aneurysms (AAAs). When etiopathogenetic associations among changes observed during the progression of the disease were not fully described, surgeons had successfully applied, although traumatic, but a rather radical method to rescue from the rupture threat. As we gained experience and knowledge about long-term outcomes, mostly concerned mortality, we realized that surgery could not be the main tactical approach to AAAs treatment due to its frequent inefficiency and failure to guarantee that the disease would be suppressed including co-morbidities, polymorphic processes and clinical manifestations. It all required more sparing treatment strategies. The situation gave rise to a more argumentative and sparing medical-and-surgical approach to treatment based on a more in-depth understanding of the etiopathogenesis of the disease whereas surgery would remain of prime importance when appropriate. The following has been developed to improve treatment outcomes for AAA: 1) Multifactorial determination of indications for surgical correction with outlining the area of relative and absolute risk of aneurysm rupture;2) Method of conservative treatment aimed to attain and maintain optimal blood pressure, target levels of cholesterol and low-density lipoproteins, as well as reduce oxidative and inflammatory processes in aorta, strengthen its wall, stabilize the disease and control co-morbidities. A four-year follow-up of patients using this developed technology has yielded more preferred results suggesting the need for narrowing indications for surgery to treat AAAs. Another advantage of the sparing approach to treat AAA is economic, due to fewer operations and implantations of stent-grafts, considering the fact that medical treatment should be used in operated subjects, too.

Effects of COL1A1 and SYTL2 on inflammatory cell infiltration and poor extracellular matrix remodeling of the vascular wall in thoracic aortic aneurysm

Background:Thoracic aortic aneurysm(TAA)is a fatal cardiovascular disease,the pathogenesis of which has not yet been clarified.This study aimed to identify and validate the diagnostic markers of TAA to provide a strong theoretical basis for developing new methods to prevent and treat this disease.Methods:Gene expression profiles of the GSE9106,GSE26155,and GSE155468 datasets were acquired from the Gene Expression Omnibus(GEO)database.Differentially expressed genes(DEGs)were identified using the"limma"package in R.Least absolute shrinkage and selection operator(LASSO),support vector machine-recursive feature elimination(SVM-RFE),random forest,and binary logistic regression analyses were used to screen the diagnostic marker genes.Single-sample gene set enrichment analysis(ssGSEA)was used to estimate immune cell infiltration in TAA.Results:A total of 16 DEGs were identified.The enrichment and functional correlation analyses showed that DEGs were mainly associated with inflammatory response pathways and collagen-related diseases.Collagen type I alpha 1 chain(COL1A1)and synaptotagmin like 2(SYTL2)were identified as diagnostic marker genes with a high diagnostic value for TAA.The expression of COL1A1 and SYTL2 was considerably higher in TAA vascular wall tissues than in the corresponding normal tissues,and there were significant differences in the infiltration of immune cells between TAA and normal vascular wall tissues.Additionally,COL1A1 and SYTL2 expression were associated with the infiltration of immune cells in the vascular wall tissue.Single-cell analysis showed that COL1A1 in TAA was mainly derived from fibroblasts and SYTL2 mainly from cluster of differentiation(CD)8+T cells.In addition,single-cell analysis indicated that fibroblasts and CD8+T cells in TAA were significantly higher than those in normal arterial wall tissue.Conclusions:COL1A1 and SYTL2 may serve as diagnostic marker genes for TAA.The upregulation of SYTL2 and COL1A1 may be involved in the inflammatory infiltration of the vessel wall and poor extracellular matrix remodeling,promoting the progression of TAA.

Surgical Treatment of Aortic Aneurysm and Aortic Dissection:A Retrospective Analysis of 122 Cases

The study summarizes the clinical experience of surgical treatments of various types of thoracic aneurysm and aortic dissection. Clinical data of 122 patients with thoracic aneurysm and aortic dissection during July 2005 to July 2008 were retrospectively analyzed. The elective operations were performed in 107 patients while emergency surgery was done in 15 cases. Different surgical strategies were employed on the basis of diseased region, including simple ascending aortic replacement （n=3）, aortic root replacement （n=43）, hemi-arch replacement/total arch replacement ＋ elephant trunk technique （n=32）, thoracic/thoracoabdominal aortic replacement （n=8） and endovascular repair （n=36）. In this series, there is 4 cases of perioperative death due to massive cerebral hemorrhage （n=1）, respiratory failure （n=1） and multiple organ dysfunction syndrome （MODS） （n=2）. Three cases developed post-operative massive cerebral infarction and the relatives of the patients abandoned treatment. Instant success rate of endovascular repair was 100%. The intimal rupture was sealed. Blood flow was unobstructed in true lumen and no false lumen was visualized. It was concluded that aggressive surgery should be considered in the patients with thoracic aneurysm and aortic dissection. Surgical procedures should vary with the location and the nature of the lesions.

Health Related Quality of Life after Treatment of Abdominal Aortic Aneurysm with Open and Endovascular Techniques—A Two-Year Follow Up

Background: Patients with Abdominal Aortic Aneurysm can be treated with two different surgical methods: Open repair (OR) or Endovascular Aortic Repair (EVAR). These two different treatments can probably result in different sense of Health related Quality of life, both in a short term and a long term perspective. The purpose of this prospective study was to examine patients’ Health related Quality of life after surgical treatment of Abdominal Aortic Aneurysm over two years using different instruments for the observations. Methods: Patients were invited consecutively to answer questionnaires before operation, and 1, 12 and 24 months after surgery. The study was conducted by using the Health related Quality of life questionnaires Short Form (SF-36) and Nottingham Health Profile (NHP). 76 patient (40 in the OR and 36 in the EVAR group) participated in the study. The mean age in the OR group were 68 years, range 52 - 80 and in the EVAR group 75 years, range 65 - 85. The results from these two groups of patients were compared to a matched reference group. Results: Patients treated with EVAR rated their Health related Quality of life significantly lower in the domain of Mental Health and Mental Component Score in relation to a matched reference population before surgery. This difference was not present two years after intervention. After one month Health related qualities of life were worse for the OR group. After two years significant improvements in relation to baseline were observed only among patients in the OR group. No such long-term benefits were seen in the EVAR group. Conclusions: As the component mental health seemed to be impaired for these study group before surgery in relation to the matched reference group, nursing and doctors care actions may be of importance during the pre-operative phase. In the short perspective Health related Quality of life is worse for OR patients than the EVAR group but in the long term perspective improvements beyond preoperative status can only be seen with OR patients.

Endovascular Abdominal Aortic Aneurysm Repair under General Anesthesia Does Not Decrease Perioperative Myocardial Ischemic Events Compared with Open Repair

Objectives: Endovascular abdominal aortic aneurysm repair (EVAR) is a common procedure for abdominal aortic aneurysm (AAA), based on minimal invasiveness compared with open surgical repair (OSR). However, general anesthesia can cause considerable perturbations in patients with AAA undergoing operative repair. The aim of this study was to compare the incidence of myocardial ischemic events in association with hemodynamic changes during EVAR and OSR under general anesthesia. Methods: We retrospectively reviewed the anesthetic and medical records of patients who underwent elective abdominal aortic aneurysm repair. ST segment changes on electrocardiography and hemodynamic changes were reviewed by the attending physicians. Results: Among 120 patients, EVAR and OSR were performed in 81 and 39 patients, respectively. There were no significant differences in preoperative morbidity between the two groups. The amount of estimated blood loss was significantly lower in EVAR than OSR. The incidence of ST?segment changes in the two groups (EVAR: 16%, OSR: 23%) was not statistically different. ST segment changes occurred mainly postoperatively at resolution of anesthesia in EVAR, compared with intraoperatively in OSR. ST segment changes were mostly accompanied by tachycardia in EVAR patients, whereas they were associated with hypotension in OSR. Conclusion: Our results demonstrated a comparable incidence of perioperative ST segment changes under general anesthesia in EVAR and OSR. Patients who undergo EVAR and develop tachycardia are at risk of myocardial ischemia at resolution of anesthesia.

Fractionated-clamping for thoracoabdominal aortic aneurysm repair: a modified Crawford technique

OBJECTIVE: To apply fractionated-clamping for repair of thoracoabdominal aortic aneurysm (TAA), and evaluate its effects in decreasing surgical mortality and severe complications, such as renal failure and paraplegia, a modified crawford procedure were prospectively evaluated. METHODS: Using modified shunting and cross-clamping techniques, modified Crawford repair in 13 thoracoabdominal aorta patients were performed in the Vascular Division at Peking Union Medical College Hospital. TAA Crawford classification: 1 type I, 2 type II, 2 type III and 3 type IV TAA. Debakey classification: 1 type I, 4 type III (including 2 ruptured aneurysms), and 1 aortic coarctation. RESULTS: Thirteen procedures were performed successfully. One died of ventricular fibrillation just before completing the operation. Surgical mortality rate was 7.7% (1/13). Postoperative complications included 1 acute necrotic pancreatitis, 1 ARDS, 1 paraplegia, 1 acute renal failure, and 2 thoracic cavity bleeding. Total complication rate was 53.8% (7/13). CONCLUSIONS: Fractionated-clamping in thoracoabdominal aortic aneurysm repair is our modified Crawford procedure and aortic bypass. Clinical results demonstrate that our procedure decreased surgical mortality and major complication rate, and also alleviated viscera ischemic injury. Fractionated-clamping in aorta replacement is a practical procedure for TAA repair under general anesthesia at normal temperature.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective Acute kidney injury （AKI） frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair （TEVAR） of type B acute aortic dissection （AAD） remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD. Methods Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease： im- proving global outcomes criteria before TEVAR. Results The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI （50.0% vs. 4.2%, respectively; P 〈 0.001）, including acute renal failure （21.4% vs. O, respectively; P 〈 0.001）, and they increased with severity of AKI （P 〈 0.001）. The maximum levels of body tem- perature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission （OR： 1.023; 95% CI： 1.003-1.044; P ： 0.0238） and bilateral renal artery involvement （OR： 19.076; 95% CI： 1.914 190.164; P = 0.0120） were strong predictors of preoperative AKI. Conclusions Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Outcome of stented elephant trunk technique for extensive thoracic aortic aneurysms

Extensive aneurysms involving the ascending aorta, aortic arch, and the descending aorta stand as a therapeutic dilemma in simultaneous management of multiple sites of pathology of the aortic arch and the descending thoracic aorta. We systematically reviewed about literatures of stented elephant trunk operation （SET） identified through searches of the electronic databasesEMBASE and Medline, and aimed to summarize studies of patients undergoing SET for extensive aneurysms. Since 1996, Kato Mintroduced a hybrid technique by using stented graft implantation to the descending aorta for treatment of thoracic aortic aneurysm or dissection. It has been describe a good option for extensive thoracic aortic aneurysms and in a fashion similar to the elephant trunk technique.

Comparison of clinical curative effect between open surgery and endovascular repair of abdominal aortic aneurysm in China

Objective To compare clinical curative effects of open surgery （OS） or endovascular repair （EVAR） for patients with abdominal aortic aneurysm （AAA） in China. Data sources We performed a comprehensive search of both English and Chinese literatures involving case studies on retrograde OS or EVAR of AAA in China from January 1976 to December 2010. Study selection According to the inclusion criteria, 76 articles were finally analyzed to compare patient characteristics, clinical success, complications, and prognosis. Results We analyzed a total of 2862 patients with 1757 undergoing OS （OS group） and 1105 undergoing EVAR （EVAR group）. There was no significant difference in the success rate of the procedures. Operative time, length of ICU stay, fasting time, duration of total postoperative stay, blood loss, and blood transfusion requirements during the procedure were significantly lower in the EVAR group. A 30-day follow up revealed more cardiac, renal, pulmonary, and visceral complications in the OS group （P 〈0.01）. Low-limb ischemia, however, was more common in the EVAR group （P 〈0.05）. The 30-day mortality rate, including aorta-related and non-aorta related mortality, was significantly lower in the EVAR group （P 〈0.01）. In the follow-up period, there were more patients with occlusions of artificial vessel and late endoleak in the EVAR group （P 〈0.01）. The overall late mortality rate was higher in the OS group （P 〈0.01）, especially non-aorta-related late mortality and mortality during the fourth to the sixth year （P 〈0.01）. Conclusions EVAR was safer and less invasive for AAA patients. Patients suffered fewer complications and recovered sooner. However, complications such as artificial vessel occlusion, low-limb ischemia, and endoleak were common in EVAR. Clinicians should carry out further research to solve these complications and improve the efficacy of EVAR.

Review of Thoracic Endovascular Aneurysm Repair (TEVAR), Spinal Cord Ischemia (SCI), Cerebrospinal Fluid (CSF) Drainage and Blood Pressure (BP) Augmentation

The object of this review is to examine the role of TEVAR in causing SCI. The anatomy and physiology of blood flow to the spinal cord is examined. The role of auto regulation of blood flow within the spinal cord is also examined. This review examines the reported results from the scientific literature of the effect of thoracic aortic aneurysm repair on spinal cord blood flow. In the light of the-se findings several conclusions can reasonably be reached. These conclusions are that the development of SCI can reasonably be predicted based on complexity and extent of the TEVAR procedure performed and BP augmentation and CSF drainage can significantly reduce the impact of SCI.

Maintenance of High Blood Pressure and Early Establishment of Pulsatile Blood Flow to the Spinal Cord during Thoracoabdominal Aortic Repair

Objectives: Despite continuous advancements in the surgical treatments for thoracoabdominal aortic aneurysms (TAAA), paraplegia remains a devastating treatment-related complication. We aimed to summarize our experience with a novel surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile blood flow to the spinal cord. Materials and Methods: Between August 2011 and October 2017, 29 patients (age, 67 ± 12 years) underwent open surgery for TAAA. According to the Crawford classification, two aneurysms were type I, eight were type II, 12 were type III, and seven were type IV. We used partial cardiopulmonary bypass under mild hypothermia in all patients except one. By maintaining distal aortic perfusion pressure at 60 - 80 mmHg and creating the distal aortic anastomosis before visceral branch reconstruction, we established early perfusion of the hypogastric arteries with native pulsatile flow. Intraoperative spinal monitoring and cerebrospinal fluid drainage were performed in 26 (90%) and 23 (79%) patients, respectively. Nineteen patients (66%) underwent reconstruction of the intercostal arteries. During perioperative management, the mean arterial pressure was kept >80 mmHg. Results: No in-hospital deaths or acute neurological complications occurred. One patient (3.4%) experienced delayed temporal paraplegia. During follow-up, aorta-related death occurred in only one patient, who developed prosthetic vascular graft infection but did not undergo repeat graft replacement. The 3-year freedom from aortic-related death was 95%. Conclusion: Our surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile flow to the spinal cord was effective in preventing spinal cord injury following open surgery for TAAA.

A Prospective Survey Comparing Patients’ Experience of a Nurse-Led Clinic and Consultant-Led Clinic for Surveillance of Patients with Dilatation of the Intrathoracic Aorta

Background: Increasing workload in consultant-led clinics often means patients to wait a long time for clinic appointments. To address this, there is an increasing trend in developing nurse-led clinics across many specialities in the National Health Service. This study aims to assess whether the implementation of a nurse-led clinic in thoracic aortic surgery will optimise the utilisation of health care services and improve overall patient satisfaction. Methods: 80 follow-up patients were asked to complete a questionnaire following their appointment in an aortic clinic, which was led either by a consultant (n = 40) or an aortic specialist nurse (n = 40). All patients seen by a nurse in the clinic were assessed by a consultant surgeon prior to the clinic for suitability. No new patients were seen by a nurse. Any patient with an aortic dimension of 5 cm or greater was seen by the consultant. If there were any complicated clinical features, the patient was seen in the consultant-led clinic. Patients were asked questions about their time spent with the respective health care professionals across 12 categories (punctuality, preparedness, understanding of concerns, clarity of speech, listening, respect, explaining, letting you talk, putting you at ease, emotional support, advice and advice for next follow-up). Patients rated each category using an ordinal scale from 0 - 10. Results: Patient scores were greater in nurse-led clinics compared to consultant-led clinics across a number of categories although only punctuality reached significance (mean 9.2 vs. 6.8, p 0.05). Conclusion: Patients were highly satisfied with the nurse-led clinic across all categories, with greater satisfaction for punctuality. These findings suggest that a nurse-led clinic can be implemented for the management of carefully selected thoracic aortic surgery patient without reduction in patient satisfaction.

A new way to produce descending thoracic aorta dissection in the dogs

To oonstruct a canine thoracic aortic dissection （TAD） model for later studying. Methods： we opened the thorax of the dog and exposed the aorta. The descending aorta right below the left innominated artery was damped. The median was cut 1/3 in depth and 1/3 in circumference. Then the head of the ballcon was put into the interspace of the median, the balloon was dilated after putting forward the tube, the normal saline was instilled into the interspace and a suit pressure was kept. The balloon proceeded alongside the separation of the median. After that the elasticity Protease was instilled into the separation maintained for 2 hours. The balloon was put out, the other 2/3 of the median in depth and the intima were cut. The external 1/3 part of the median and the adventitia were sutured. At last the chest wall was dosed. Results： TAD model was established instantly, proved by angiography, MRI and autopsy. Conclusion： it is applicable to construction of a canine TAD model by this procedure.

Hybrid Endovascular Aorta Repair with Simultaneous Supra-aortic Branch or Iliac Branch Revascularization

Objective To describe a hybrid endovascular procedure for aorta repair with different kinds of bypass followed by concomitant placement of stent graft in the aorta. Methods From June 2007 to May 2008, 5 consecutive patients who presented with aortic aneurysm or dissection were treated with a new hybrid aorta repair technique. Complete surgical rerouting of supra-aortic vessels was simultaneously created by endovascular repair of aortic arch aneurysm with stent graft. Hybrid left carotid-subclavian bypass with stent graft deployment covering the ostium of the left subclavian artery was performed in a Debakey type III aortic dissection case. The supra-aortic branch was revascularized in 2 cases from ascending aorta to bilateral common carotid arteries using a 16-8 mm bifurcated graft, then total aortic arch and descending artery was occluded with stent-graft. The left carotid artery to the left subclavian artery bypass was created in 1 case, followed by stent-graft deployment. Two cases of infrarenal abdominal aortic aneurysm underwent left external iliac artery to left internal iliac artery bypass by a retroperineal route, then hybrid procedure was performed with bifurcated stent-graft. All stent grafts were deployed via a retrograde femoral artery approach in 5 patients. Results Technical success with complete aneurysmal exclusion was achieved in all patients. There was no incidence of encloleak. During a follow-up period of 2 to 10 months, documented perioperative neurologic events did not occur in all patients. One patient suffered from adult respiratory distress syndrome. After received tracheostomy, he recovered later. There was one death resulting from a postoperative myocar- dial infarction. Conclusion Hybrid arch repair provides an alternative therapy to patients otherwise considered prohibitively high risk for traditional open arch and thoracoabdominal aorta repair.

Antegrade in situ laser fenestration of aortic stent graft during endovascular aortic repair:A case report

BACKGROUND The endovascular repair of juxtarenal abdominal aortic aneurysms(JAAA)usually requires combination treatment with various stent graft modifications to preserve side branch patency.As a feasible technique,according to the situation,antegrade in situ laser fenestration still needs to be improved.CASE SUMMARY This report describes a case that was successfully treated with endovascular repair facilitated by antegrade in situ laser fenestration while maintaining renal arterial flow.Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of the renal artery ostium.With the bare stent region unreleased,renal artery perfusion could be maintained and accurate positioning could be achieved by angiography in real time.CONCLUSION This study suggests the feasibility and short-term safety of this novel antegrade in situ laser fenestration technique for select JAAA patients.